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Toronto Notes 2019 Pregnancy-Related Complications
• surgical
■ <14 wk:
◆ manual vacuum aspiration – up to about 8-9 weeks with hand held aspiration device
◆ suction dilatation + aspiration ± curettage – may involve pre-surgical preparation of cervix with
laminaria tents and/or misoprostol
■ 14-24weeks:dilatationandevacuation;pre-surgicalpreparationofcervixrequiredwithlaminariatents
■ pain or discomfort during procedure mitigated by use of appropriate analgesia/sedation/anesthesia
(including paracervical blocks)
■ rare complications (1-5%): laceration of cervix, infection/endometritis, retained products of
conception, ongoing pregnancy
■ very rare complications: (0.1-2%) : hemorrhage, perforation of uterus, Asherman’s syndrome
(adhesions within the endometrial cavity causing amenorrhea/infertility), future preterm birth
(controversial and likely only with repeated abortion) • counselling
■ options counselling always provided; always offer possibility of carrying pregnancy with/without adoption
■ offer future contraception and family planning services
■ ensure follow-up
Pregnancy-Related Complications
First and Second Trimester Bleeding
Approach to the Patient with Bleeding in T1/T2
History
• riskfactorsforectopicpregnancy(seeEctopicPregnancy,GY20) • previousspontaneousabortion
• recenttrauma
• characteristicsofthebleeding(includinganytissuepassed)
• characteristicsofthepain(crampingpainsuggestsspontaneousabortion)
• historyofcoagulopathy
• gynecological/obstetrichistory
• fatigue,dizziness,syncopalepisodesduetohypovolemia,fever(maybeassociatedwithsepticabortion)
Physical
• vitals(includingorthostaticchanges)
• abdomen(symphysisfundalheight,tenderness,presenceofcontractions)
• perineum(signsoftrauma,genitallesions)
• speculumexam(cervicalosopenorclosed,presenceofactivebleeding/clots/tissue)
• pelvicexam(uterinesize,adnexalmass,uterine/adnexaltenderness,cervicalmotiontenderness)
Investigations
• β-hCG(maybelowerthanexpectedforGAinspontaneousabortion,canbeusedtodiagnoseviable pregnancy vs. ectopic pregnancy vs. abortion)
• U/S(confirmintrauterinepregnancyandfetalviability)
• CBC
• groupandscreen
Treatment
• IVresuscitationforhemorrhagicshock • treattheunderlyingcause
Gynecology GY19
Bleeding in Pregnancy Definitions
• First trimester bleeding: vaginal bleeding within the first 12 wk
• Second trimester bleeding: 12-20 wk
Differential Diagnosis
• Physiologic bleeding: spotting, due to implantation of placenta – reassure and check serial β-hCGs
• Abortion (threatened, inevitable, incomplete, complete)
• Abnormal pregnancy (ectopic, molar) (see Hydatidiform Mole, GY48)
• Trauma (post-coital or after pelvic exam) • Genital lesion (e.g. cervical polyp,
neoplasms)
• Subchorionic hematoma
Every woman of childbearing age presenting to ER with abdominal or pelvic pain should have β-hCG measured